Enhanced Recovery Programs for Colorectal Surgery and Postoperative Acute Kidney Injury: Results From a Systematic Review and Meta-Analysis of Observational Studies

Implementation of enhanced recovery protocol did not increase rates of acute kidney injury in open gynecologic oncology surgery: A single-institution experience

OBJECTIVE

To compare the incidence of acute kidney injury (AKI) among patients undergoing gynecologic surgery before and after implementing an Enhanced Recovery After Surgery (ERAS) pathway.

METHODS

We conducted a retrospective review of medical records from Mayo Clinic during three time periods when ERAS was used, focusing on patients who underwent open gynecologic surgery. AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria. We used inverse-probability of treatment weighting (IPTW) to adjust for baseline covariates between pre-ERAS (135 patients) and post-ERAS (486 patients) cohorts. Statistical comparisons were made using t-test, Wilcoxon rank-sum, chi-square or Fisher's exact test, and univariate logistic regression with odds ratio (OR) and 95 % confidence interval (CI).

RESULTS

Pre-IPTW, the AKI incidence was similar between cohorts (10.4 % vs 8.4 %, p = 0.48), and the odds of AKI for post-ERAS patients compared to pre-ERAS was not significant (OR 0.80, 95 % CI 0.42-1.51). After IPTW-adjustment, the AKI incidence remained comparable (10.3 % vs 8.1 %, p = 0.41), with the odds ratio unchanged (OR 0.76, 95 % CI 0.40-1.45). AKI patients were older (mean 67.0 vs 62.4 years, p < 0.01), had higher ASA scores (61.8 % vs 45.2 %, p = 0.02), lower preoperative hemoglobin (median 10.8 vs 12.5 g/dL, p < 0.01), longer surgeries (median 331 vs 222 min, p < 0.01), greater intraoperative blood loss (median 800 vs 500 mL, p < 0.01), more transfusions (56.4 % vs 29.3 %, p < 0.01), and higher fluid volumes (median 5750 vs 4165 mL, p < 0.01).

CONCLUSION

The ERAS pathway did not significantly impact AKI incidence in gynecologic surgery patients. AKI remains associated with increased postoperative complications, highlighting the need for improved risk prediction and preventive strategies.

Effect of rigorous fluid management using monitoring of ECW ratio by bioelectrical impedance analysis in critically ill postoperative patients: A prospective, single-blind, randomized controlled study

BACKGROUND & AIMS

Precise assessment of postoperative volume status is important to administrate optimal fluid management. Bioelectrical impedance analysis (BIA) which measures the body composition using electric character. Extracellular water (ECW) ratio by BIA represented as the ratio of ECW to total body water (TBW) and is known to reflect the hydration status. Based on this, we aimed to determine whether aggressive fluid control using ECW ratio could improve clinical outcomes through a single blind, randomized controlled trial.

METHODS

From November 2021 to December 2022, intensive care unit (ICU) patients admitted after surgery were randomly assigned to an intervention group or a control group whether postoperative fluid management was controlled via BIA. Among patients in the intervention group, dehydrated patients received a bolus infusion with crystalloid fluid whereas diuretics were administrated to overhydrated patients until the value of ECW ratio fell within its normal setting range (0.390-0.406). Contrarily, BIA was performed once a day for the control group. Patients in the control group received traditional fluid treatment regardless of BIA results. Primary outcome was in-hospital mortality in two groups. The secondary outcomes were postoperative morbidities, 28-day mortality.

RESULTS

77 patients of the intervention group and 90 patients of the control group were finally analyzed. The in-hospital mortality (0 in intervention, 4.4% in control, p = 0.125) and 28-day mortality (1.3% in intervention, 14.4% in control, p = 0.002) showed lower incidence in the intervention group than in the control group. In multivariate analysis, the overhydrated status whose ECW ratio exceeding 0.406 [odds ratio (OR): 2.731, 95% confidence interval (CI): 1.001-7.663, p = 0.049] and high capillary leak index (CLI) value at ICU admission (OR: 1.024, 95% CI: 1.008-1.039, p = 0.002) were risk factors of postoperative morbidities. Regarding the 28-day mortality, high CLI value (OR: 1.025, 95% CI: 1.002-1.050, p = 0.037) and traditional strategy without BIA monitoring (OR: 9.903, 95% CI: 1.095-89.566, p = 0.041) were the significant predisposing factors.

CONCLUSION

Our results revealed the rigorous fluid treatment with volume control based on ECW ratio by BIA failed to achieve significant improvement in in-hospital mortality, but it could reduce 28-day mortality of ICU patients. Monitoring of ECW ratio may help establish optimal fluid treatment strategies for postoperative ICU patients who are susceptible to fluid imbalances with fluid overload.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06097923, retrospectively registered on October 16, 2023, https://clinicaltrials.gov/study/NCT06097923?term=NCT06097923&rank=1.

Goal-Directed Fluid Therapy Does Not Impact Renal Outcomes in an Enhanced Recovery Program

BACKGROUND

Goal-directed fluid therapy (GDFT) has been proposed as a cornerstone for Enhanced Recovery After Surgery (ERAS) programs, particularly among high-risk patients undergoing high-risk surgery. However, due to the increased advocacy of euvolemia before surgery, the utility of GDFT in the context of ERAS is being questioned. Our primary objective was to determine whether GDFT has any impact on daily postoperative renal outcomes among high-risk patients undergoing thoracic surgery in an ERAS program.

METHODS

All patients included in this study were high-risk with a baseline GFR below 90 mL/min/1.73m² and classified as American Society of Anesthesiologists status III/IV. Patients were categorized into two groups according to the intraoperative use of GDFT. Both groups were matched in a 1:1 fashion using propensity scores. Our renal outcomes included changes in daily glomerular filtration rates (GFRs) from post-anesthesia care unit through postoperative day 5.

RESULTS

In total 451 matched pairs were included in this analysis. Both groups had similar demographics and clinical characteristics. Patients treated with GDFT received more ephedrine (5mg [0-15] vs 0mg [0-15], P=0.03) and less volume of fluids (1163±484mL vs 1246±626mL, P=0.03) compared to those in the standard group. The incidence of AKI was similar in both groups (5.1% in the GDFT group vs 7.1% in non-GDFT group, P=0.57). Mixed effect analysis showed no significant differences in the trajectory of postoperative GFRs between both groups (P=0.59).

CONCLUSIONS

GDFT does not impact postoperative renal function compared to standard of care among high-risk patients in an ERAS program for thoracic pulmonary surgery.